ACT Call Questions & Answers From Jurisdiction A (NHIC)

October 09, 2013

ACT Call Questions and Answers – September 11, 2013

The DME MAC Jurisdiction A quarterly ACT call was conducted Wednesday, September 11, 2013 as a teleconference/webinar and was based on the Affordable Care Act (ACA) Face-to-Face requirements. A brief presentation was provided followed by an operator assisted Q&A session.

Note: Individual claim specific questions, questions not general in nature, and questions that did not make sense are not included in this document. In addition, some questions may be rewritten to establish clarity. As advised during the call, please contact Customer Service to address individual questions.

Q1: What should the date of encounter be, if the physician is seeing the patient almost daily in a SNF? Is it the date of discharge?

A1: The date the physician evaluated the patient and determined the need for the specific item ordered. The medical record should address that the relevant LCD or NCD criteria are met.

Q2: When a beneficiary is being discharged from a facility, what is the time frame prior to discharge that a face-to-face can be completed?

A2: The face-to-face exam must occur within six (6) months prior to writing the order.

Q3: Can the order and the face-to-face documentation be in a single form or does the physician need to document the face-to-face in the medical records?

A3: The face-to-face evaluation must be documented in the medical record. Therefore, it would be two separate documents.

Q4: How are physicians being educated by CMS or Medicare?

A4: The DME MACs are working with the A/B MACs to distribute information and educational material to the physicians.

Q5: When the physician signs/co-signs a face-to-face encounter, is he attesting that the encounter was conducted or that the physician agrees with the documentation?

A5: The physician is attesting that the face-to-face was conducted.

Q6: Are there, or will there soon be, face-to-face requirements for prosthetic and orthotic orders?

A6: Orthotics and Prosthetics were not included in Affordable Care Act Face-to-Face requirements, and therefore were not included in MM8304. Any requirements for an in-person evaluation would be listed in the specific Local Coverage Determination (LCD). For example, there is an in-person evaluation required for Therapeutic Shoes for Persons with Diabetes.

Q7: Is there a limit on the amount of time between when the PA/NP/CNS performs the face-to-face and the physician signs the record?

A7: The medical record must be co-signed prior to delivery of the item.

Q8: Does the face-to-face requirement apply to DME oral oncology or IVIG?

A8: Only the items listed in MM8304 are affected by this requirement.

Q9: Does the WOPD and face-to-face requirement apply when a patient elects a new 60 month rental or when transitioning to a competitive bid supplier?

A9: Yes. Any time a new order is required a face-to-face evaluation is also needed.

Note: MM8304 affects items being initially ordered and/or beneficiaries transferring to competitive bid suppliers on or after 7/01/2013.

Q10: If a beneficiary was seen 5 months ago and now needs a hospital bed or wheelchair, how would the physician know if this equipment is needed?

A10: The requirement of the face-to-face is to document the need for the item that is being ordered. Therefore, if the previous physician’s visit did not document the need for the item, a new face-to-face will be required.

Q11: How will homebound patients meet the new requirements of the Affordable Care Act Face-to-Face requirement?

A11: There are no exceptions. Accommodations must be made to meet the face-to-face requirements. The face-to-face requirement includes encounters conducted via the Centers for Medicare & Medicaid Services (CMS)-approved use of telehealth (as described in Chapter 15 of the “Medicare Benefit Policy Manual” and Chapter 12 of the “Medicare Claims Processing Manual“).

Q12: How detailed do the physicians notes have to be to meet Medicare’s requirements?

A12: The medical record must document that the beneficiary was evaluated and/or treated for a condition that supports the item(s) of DME ordered. There must be sufficient medical information included in the face-to-face record to demonstrate that the applicable coverage criteria are met. Refer to the applicable Local Coverage Determination (LCD) for information about the medical necessity criteria for the item(s) being ordered.

Q13: Do suppliers need a prior approval according to MM8304?

A13: A prior approval is not afforded to the items listed in MM8304. However, this does not void the eligibility for Advanced Determination of Medicare Coverage (ADMC) requests for specific codes listed in the CR, such as K0005 and K0009 along with any other codes that are eligible for ADMCs.

Q14: Is the face-to-face requirement needed for supplies of base equipment that is listed in MM8304?

A14: Only items listed in MM8304 need the face-to-face evaluation. No supplies are included in the list.

Q15: How will the new requirement work for items that are repair parts of a main piece of DME?

A15: If the replacement part is an item listed in MM8304, the guidelines for the face-to-face will be required to be met.

Q16: Is the Written Order required before delivery?

A16: Yes. A written order is required prior to delivery of any item listed in MM8304.

Q17: Does the detailed written order have to be signed by the same physician who completed the face-to-face exam? Can there be exceptions?

A17: Generally, the same physician who conducted the face-to-face would be the same physician who wrote the order. There can be limited exceptions to the rule (i.e. group practice, hospitalist, etc.) and there must be documentation to support the reason a different physician wrote the detailed written order and to indicate the physician relationship.

Q18: Is the 10/01/2013 enforcement date based off the date of service or date of submission?

A18: The enforcement date is based on the date of service.

Q19: Specifically what HCPCS codes are affected?

A19: The lists of affected HCPCS codes are found in MM8304.

Q20: Are documentation templates allowed?

A20: Yes. However, the templates should be formatted to allow sufficient narrative information to be provided by the treating physician in order to fully assess the patient’s medical need.

Q21: Is a face-to-face required when replacing batteries?

A21: Batteries are not listed within MM8304. Therefore, if an item is not on the list, it does not require the face-to-face evaluation.

Q22: Do we use an RA or RB modifier when replacing batteries?

A22: The RB modifier should be used when billing for replacement parts such as batteries.

Q23: If the physician provides a length of need of 7 months on an order and the patient continues to require the equipment, is the patient required to now have another face-to-face evaluation?

A23: Yes. Anytime a new order is required, a new face-to-face must also be conducted for any item listed in MM8304.

Q24: Prescription pads only have one date field located in the upper right corner. Is that not sufficient as a date for the physician signature?

A24: No. The physician must write the date next to their signature.

Q25: Does MM8304 affect Medicare Secondary beneficiaries?

A25: Yes. All Medicare requirements would still be applicable.

Q26: We are a home infusion company and bill the E0781; however; it is not on the list in CR8304. Does this requirement apply to the E0781?

A26: If an item is not on the list in MM8304, currently it does not require the face-to-face evaluation. The list is subject to be updated annually by CMS.

Q27: Scenario: The surgeon has evaluated a beneficiary and recommended physical therapy. The Physical Therapist then recommends a manual wheelchair. The surgeon is in surgery when the beneficiary is being discharged and cannot sign the evaluation until he is out of surgery. Is that going to be an issue?

A27: The law requires there be an in-person visit with the physician who writes the order. It not only pertains to “seeing” a beneficiary, there must also be information documented in the medical record about the need for the item that is ordered.

Q28: Does the signature of the physician co-signing the documents need to be prior to delivery or prior to claim submission?

A28: All requirements set forth in MM8304 must be completed prior to delivery of the item ordered.

Q29: Are templates allowed as long as there is a space for a doctor to write a narrative, sign and date? Also can this be in place of or added to the medical record?

A29: Most templates are designed with a very narrow set of issues related to reimbursement along with not having enough detail. During past audits, when the nurses were looking for all the specifics of a patient’s medical condition, it was either missing, or not enough detail was provided. Physicians tend to answer questions within a template in short and incomplete answers. Although discouraged, templates can be created. However, the template must address all the issues in the NCD, LCD, etc., making this type of form/template very lengthy.

Q30: Does the delay in active enforcement mean that a supplier that delivers an item ordered on or after July 01, 2013, and submits a claim, but doesn’t have the face-to-face documentation on hand, will not be subject to denial for failure to have such documentation?

A30: The requirements are effective July 01, 2013; CMS has not given any instruction on the time limit for post-pay audits and requiring the face-to-face evaluation. DME MAC A does not conduct post-pay audits. However, there are other contractors that do conduct post-pay audits (i.e., CERT, RA, etc.). CMS has not issued any instruction that puts any limitations on the dates that can be selected.

Q31: Does the delay in active enforcement affect the written order prior to delivery (WOPD) as well as the face-to-face requirement?

A31: The WOPD is part of the ACA Face-to-Face requirement and the delay in enforcement would apply. Unless it was an item that already required a Written Order Prior to Delivery based on the CMS Program Integrity Manual requirements.

Q32: Suppliers have been able to obtain a verbal order in the past. Does this new requirement eliminate the option for verbal orders?

A32: For items affected by MM8304, an item cannot be dispensed based on a verbal order. A Written Order Prior to Delivery must be obtained prior to delivering the item to the beneficiary.

Q33: When will the LCDs and Supplier Manual be updated with the changes from MM8304?

A33: The DME MAC A Supplier Manual is updated with these changes. The LCDs will be updated once CMS provides clarification on some specific questions from the DMDs. The fact that the policies are not currently updated does not waive the face-to-face requirement for all items in MM8304.

Q34: If a supplier takes on a beneficiary due to competitive bid, would the contract supplier need to obtain a new WOPD and face-to-face evaluation for the beneficiary or would they be able to use the information from the old supplier?

A34: Yes. A new WOPD and face-to-face evaluation would need to be obtained. Competitive bidding does not override this requirement. Since it is a new supplier, all requirements of MM8304 would need to be met.

Q35: When did the physician’s start receiving education on this new requirement?

A35: The DME MACs have been working with the A/B MACs to distribute this information. Also, it is the responsibility of the supplier to educate the physician community on what the requirements must be met for reimbursement of DMEPOS items.

Q36: Are glucose monitors allowed to be dispensed on a verbal order?

A36: No. Glucose monitors are among the list of items that must follow all requirements listed in MM8304, which includes a Written Order Prior to Delivery.

Q37: When the face-to-face evaluation and detailed written order is obtained and additional supplies are needed, is a new detailed written order required?

A37: Supplies are not on the list of items which require a face-to-face evaluation based on the Affordable Care Act. Therefore, a new order is only required in the following circumstances:

  • There is a change of supplier
  • There is a change in the item(s), frequency of use, or amount prescribed
  • There is a change in the length of need or a previously established length of need expires
  • State law requires a prescription renewal

Q38: For items that require a Certificate of Medical Necessity (CMN), can the CMN take the place of the DWO?

A38: Yes. As long as it has all the required elements of a detailed written order and is obtained prior to delivery.

Q39: The required information is not initially obtained and a beneficiary choses to pay privately by signing an ABN. If afterwards the DWO and face-to-face evaluation is then obtained, could Medicare be billed?

A39: The item would need to be picked-up and redelivered to the beneficiary once the requirements of the face-to-face evaluation are met.